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PUBLIC,- HEALTH SER- ICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL IfEALTII DIVISION <br />Ernest NI. f'q(iulolo, M.U., M.I'.IL, Acling Ifenllh Officer <br />445 N. San Joaquin Slice( a P. 0. Ron 198 a Slocklon, CA 95201-0388 <br />1119/468-3410 <br />f—i� GON� <br />APPLICA'VION FOR PERMfI" 10 CLOSE <br />UNDERGROUND S I ORAGE TANKS STORING HAZARDOUS MATERIALS <br />OENERAL INS'TRUCi'IONS: <br />(i <br />I. Submit nil Information in Iriplicate. Answer all questions, leaving no blanks. One copy will be <br />returned to Ilse applicant with conunems. <br />(( 2. Include a detailed site map on a separate sheet of paper, showing the location of the tanks(s), piping, <br />streets, adincent properties (north toward the top of the page), nearby septic ranks, leachnelds, water <br />wells, buildings, underground public utility lines (including water, sanitary sewer and storm sewer), <br />and distance of piping front tank to dispensers. If underground utilities are not included on the site <br />map, you must state In willing that USA Dig will be contacted prior to excavation activities. <br />(( <br />I. Complete page 3, "Applicnthmn for Underground Tmnk Closure Permit". <br />4. Complete page 9, "Aulhorizntlon to Relense Aonlylicnl Data". 1his form must be signed and dared <br />by the OWNERAWERATOII of tike facility. <br />(( 5. Submit the appropriate fees and complete page 11, the "Underground Tank Program Fee Worksheet". <br />6. Coaq,lete all questions on page 10, the Public health Services -Environmental Health Division <br />(PIIS-FlID)Storage Tank Dlsposilion Trnckhtg Record", except those requiring a <br />sipnnture and date or tank removal. 'I he holder of lite permit shall be responsible for ensuring that <br />this form is completed and returned to PI IS -El ID within 30 days of the tank removal. <br />i ( 7. Submlt a "Sire Ilenith & Surely I'lnn" as ml addendum l0 this application, to address nil potential <br />hazards for fids specific job site. Refer to the Site Safety Plan Guidance Document for specifics. <br />(( <br />R. if facility is located outside of the city limits, $"bull( a "Ilnckfill Excavation Cerfiflente" as required <br />by the County of San .lonquin Building Department and the incorporated City Building Departments, <br />pursuant to the Uniform Building Code S'IU 70-11. <br />i 9. Obinin a "Grnding and Excnvolimt Permit" from the City of Tracy Building Division prior to PHS - <br />MID approval of the closure plan. <br />(( RI. 'l lie maximum review time for Closure Plans is 15 working days from receipt of the adequately <br />completed plan. If gross deficiencies are identified, an addendum will be required with a S78.00/hour <br />fee and the review will begin on the date of resubmittal. <br />( ( 11. Submit verincation of tine fie permit from the approprinte fire district at the removal inspection. <br />(( 12. Advance Inspection notice of of least 48 hours is required by PIIS-EHD. <br />FI l 23 (107 (Revised 11/1/92) Page t <br />A 111,610" of Sen Joagaln Cnuno Ilallh Cate Servicer <br />